II 

115TH CONGRESS 

1ST SESSION S. 1511 

To bring stability to the individual insurance market, make insurance coverage 

more affordable, lower prescription drug prices, and improve Medicaid. 

IN THE SENATE OF THE UNITED STATES 

JUNE 29, 2017 

Mr. CARDIN introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To bring stability to the individual insurance market, make 

insurance coverage more affordable, lower prescription 

drug prices, and improve Medicaid. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Keeping Health Insurance Affordable Act of 2017’’. 

6 (b) TABLE OF CONTENTS.—The table of contents for 

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—MARKETPLACE STABILITY AND SECURITY 

Sec. 101. Individual Market Reinsurance Fund. 

Sec. 102. Public health insurance option. 

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TITLE II—HEALTH CARE FINANCIAL ASSISTANCE 

Sec. 201. Increase in eligibility for premium assistance tax credits. 

Sec. 202. Enhancements for reduced cost sharing. 

TITLE III—DRUG PRICING 

Sec. 301. Requiring drug manufacturers to provide drug rebates for drugs dispensed to low-income individuals. 

Sec. 302. Negotiation of prices for medicare prescription drugs. 

Sec. 303. Guaranteed prescription drug benefits. 

Sec. 304. Full reimbursement for qualified retiree prescription drug plans. 

TITLE IV—MEDICAID COLLABORATIVE CARE MODELS 

Sec. 401. Enhanced FMAP for medical assistance provided through a collaborative care model. 

1 TITLE I—MARKETPLACE 

2 STABILITY AND SECURITY 

3 SEC. 101. INDIVIDUAL MARKET REINSURANCE FUND. 

4 (a) ESTABLISHMENT OF FUND.— 

5 (1) IN GENERAL.—There is established the ‘‘In6 dividual Market Reinsurance Fund’’ to be adminis7 tered by the Secretary to provide funding for an in8 dividual market stabilization reinsurance program in 

9 each State that complies with the requirements of 

10 this section. 

11 (2) FUNDING.—There is appropriated to the 

12 Fund, out of any moneys in the Treasury not other13 wise appropriated, such sums as are necessary to 

14 carry out this section (other than subsection (c)) for 

15 each calendar year beginning with 2018. Amounts 

16 appropriated to the Fund shall remain available 

17 without fiscal or calendar year limitation to carry 

18 out this section. 

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1 (b) INDIVIDUAL MARKET REINSURANCE PRO2 GRAM.— 

3 (1) USE OF FUNDS.—The Secretary shall use 

4 amounts in the Fund to establish a reinsurance pro5 gram under which the Secretary shall make reinsur6 ance payments to health insurance issuers with re7 spect to high-cost individuals enrolled in qualified 

8 health plans offered by such issuers that are not 

9 grandfathered health plans or transitional health 

10 plans for any plan year beginning with the 2018 

11 plan year. This subsection constitutes budget au12 thority in advance of appropriations Acts and rep13 resents the obligation of the Secretary to provide 

14 payments from the Fund in accordance with this 

15 subsection. 

16 (2) AMOUNT OF PAYMENT.—The payment 

17 made to a health insurance issuer under subsection 

18 (a) with respect to each high-cost individual enrolled 

19 in a qualified health plan issued by the issuer that 

20 is not a grandfathered health plan or a transitional 

21 health plan shall equal 80 percent of the lesser of— 

22 (A) the amount (if any) by which the indi23 vidual’s claims incurred during the plan year 

24 exceeds— 

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1 (i) in the case of the 2018, 2019, or 

2 2020 plan year, $50,000; and 

3 (ii) in the case of any other plan year, 

4 $100,000; or 

5 (B) for plan years described in— 

6 (i) subparagraph (A)(i), $450,000; 

7 and 

8 (ii) subparagraph (A)(ii), $400,000. 

9 (3) INDEXING.—In the case of plan years be10 ginning after 2018, the dollar amounts that appear 

11 in subparagraphs (A) and (B) of paragraph (2) shall 

12 each be increased by an amount equal to— 

13 (A) such amount; multiplied by 

14 (B) the premium adjustment percentage 

15 specified under section 1302(c)(4) of the Af16 fordable Care Act, but determined by sub17 stituting ‘‘2018’’ for ‘‘2013’’. 

18 (4) PAYMENT METHODS.— 

19 (A) IN GENERAL.—Payments under this 

20 subsection shall be based on such a method as 

21 the Secretary determines. The Secretary may 

22 establish a payment method by which interim 

23 payments of amounts under this subsection are 

24 made during a plan year based on the Secmstockstill on DSK30JT082PROD with BILLS

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1 retary’s best estimate of amounts that will be 

2 payable after obtaining all of the information. 

3 (B) REQUIREMENT FOR PROVISION OF IN4 FORMATION.— 

5 (i) REQUIREMENT.—Payments under 

6 this subsection to a health insurance issuer 

7 are conditioned upon the furnishing to the 

8 Secretary, in a form and manner specified 

9 by the Secretary, of such information as 

10 may be required to carry out this sub11 section. 

12 (ii) RESTRICTION ON USE OF INFOR13 MATION.—Information disclosed or ob14 tained pursuant to clause (i) is subject to 

15 the HIPAA privacy and security law, as 

16 defined in section 3009(a) of the Public 

17 Health Service Act (42 U.S.C. 300jj– 

18 19(a)). 

19 (5) SECRETARY FLEXIBILITY FOR BUDGET

20 NEUTRAL REVISIONS TO REINSURANCE PAYMENT

21 SPECIFICATIONS.—If the Secretary determines ap22 propriate, the Secretary may substitute higher dollar 

23 amounts for the dollar amounts specified under sub24 paragraphs (A) and (B) of paragraph (2) (and ad25 justed under paragraph (3), if applicable) if the Secmstockstill on DSK30JT082PROD with BILLS

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1 retary certifies that such substitutions, considered 

2 together, neither increase nor decease the total pro3 jected payments under this subsection. 

4 (c) OUTREACH AND ENROLLMENT.— 

5 (1) IN GENERAL.—During the period that be6 gins on January 1, 2018, and ends on December 31, 

7 2020, the Secretary shall award grants to eligible 

8 entities for the following purposes: 

9 (A) OUTREACH AND ENROLLMENT.—To 

10 carry out outreach, public education activities, 

11 and enrollment activities to raise awareness of 

12 the availability of, and encourage enrollment in, 

13 qualified health plans. 

14 (B) ASSISTING INDIVIDUALS TRANSITION

15 TO QUALIFIED HEALTH PLANS.—To provide as16 sistance to individuals who are enrolled in 

17 health insurance coverage that is not a qualified 

18 health plan enroll in a qualified health plan. 

19 (C) ASSISTING ENROLLMENT IN PUBLIC

20 HEALTH PROGRAMS.—To facilitate the enroll21 ment of eligible individuals in the Medicare pro22 gram or in a State Medicaid program, as appro23 priate. 

24 (D) RAISING AWARENESS OF PREMIUM AS25 SISTANCE AND COST-SHARING REDUCTIONS.— 

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1 To distribute fair and impartial information 

2 concerning enrollment in qualified health plans 

3 and the availability of premium assistance tax 

4 credits under section 36B of the Internal Rev5 enue Code of 1986 and cost-sharing reductions 

6 under section 1402 of the Patient Protection 

7 and Affordable Care Act, and to assist eligible 

8 individuals in applying for such tax credits and 

9 cost-sharing reductions. 

10 (2) ELIGIBLE ENTITIES DEFINED.— 

11 (A) IN GENERAL.—In this subsection, the 

12 term ‘‘eligible entity’’ means— 

13 (i) a State; or 

14 (ii) a nonprofit community-based or15 ganization. 

16 (B) ENROLLMENT AGENTS.—Such term 

17 includes a licensed independent insurance agent 

18 or broker that has an arrangement with a State 

19 or nonprofit community-based organization to 

20 enroll eligible individuals in qualified health 

21 plans. 

22 (C) EXCLUSIONS.—Such term does not in23 clude an entity that— 

24 (i) is a health insurance issuer; or 

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1 (ii) receives any consideration, either 

2 directly or indirectly, from any health in3 surance issuer in connection with the en4 rollment of any qualified individuals or em5 ployees of a qualified employer in a quali6 fied health plan. 

7 (3) PRIORITY.—In awarding grants under this 

8 subsection, the Secretary shall give priority to 

9 awarding grants to States or eligible entities in 

10 States that have geographic rating areas at risk of 

11 having no qualified health plans in the individual 

12 market. 

13 (4) FUNDING.—Out of any moneys in the 

14 Treasury not otherwise appropriated, $500,000,000 

15 is appropriated to the Secretary for each of calendar 

16 years 2018 through 2020, to carry out this sub17 section. 

18 (d) REPORTS TO CONGRESS.— 

19 (1) ANNUAL REPORT.—The Secretary shall 

20 submit a report to Congress, not later than January 

21 21, 2019, and each year thereafter, that contains 

22 the following information for the most recently 

23 ended year: 

24 (A) The number and types of plans in each 

25 State’s individual market, specifying the nummstockstill on DSK30JT082PROD with BILLS

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1 ber that are qualified health plans, grand2 fathered health plans, or health insurance cov3 erage that is not a qualified health plan. 

4 (B) The impact of the reinsurance pay5 ments provided under this section on the avail6 ability of coverage, cost of coverage, and cov7 erage options in each State. 

8 (C) The amount of premiums paid by indi9 viduals in each State by age, family size, geo10 graphic area in the State’s individual market, 

11 and category of health plan (as described in 

12 subparagraph (A)). 

13 (D) The process used to award funds for 

14 outreach and enrollment activities awarded to 

15 eligible entities under subsection (c), the 

16 amount of such funds awarded, and the activi17 ties carried out with such funds. 

18 (E) Such other information as the Sec19 retary deems relevant. 

20 (2) EVALUATION REPORT.—Not later than Jan21 uary 31, 2022, the Secretary shall submit to Con22 gress a report that— 

23 (A) analyzes the impact of the funds pro24 vided under this section on premiums and enmstockstill on DSK30JT082PROD with BILLS

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1 rollment in the individual market in all States; 

2 and 

3 (B) contains a State-by-State comparison 

4 of the design of the programs carried out by 

5 States with funds provided under this section. 

6 (e) DEFINITIONS.—In this section: 

7 (1) SECRETARY.—The term ‘‘Secretary’’ means 

8 the Secretary of the Department of Health and 

9 Human Services. 

10 (2) FUND.—The term ‘‘Fund’’ means the Indi11 vidual Market Reinsurance Fund established under 

12 subsection (a). 

13 (3) GRANDFATHERED HEALTH PLAN.—The 

14 term ‘‘grandfathered health plan’’ has the meaning 

15 given that term in section 1251(e) of the Patient 

16 Protection and Affordable Care Act. 

17 (4) HIGH-COST INDIVIDUAL.—The term ‘‘high18 cost individual’’ means an individual enrolled in a 

19 qualified health plan (other than a grandfathered 

20 health plan or a transitional health plan) who incurs 

21 claims in excess of $50,000 during a plan year. 

22 (5) STATE.—The term ‘‘State’’ means each of 

23 the 50 States and the District of Columbia. 

24 (6) TRANSITIONAL HEALTH PLAN.—The term 

25 ‘‘transitional health plan’’ means a plan continued 

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1 under the letter issued by the Centers for Medicare 

2 & Medicaid Services on November 14, 2013, to the 

3 State Insurance Commissioners outlining a transi4 tional policy for coverage in the individual and small 

5 group markets to which section 1251 of the Patient 

6 Protection and Affordable Care Act does not apply, 

7 and under the extension of the transitional policy for 

8 such coverage set forth in the Insurance Standards 

9 Bulletin Series guidance issued by the Centers for 

10 Medicare & Medicaid Services on March 5, 2014, 

11 February 29, 2016, and February 13, 2017. 

12 SEC. 102. PUBLIC HEALTH INSURANCE OPTION. 

13 (a) IN GENERAL.—Part 3 of subtitle D of title I of 

14 the Patient Protection and Affordable Care Act (Public 

15 Law 111–148) is amended by adding at the end the fol16 lowing new section: 

17 ‘‘SEC. 1325. PUBLIC HEALTH INSURANCE OPTION. 

18 ‘‘(a) ESTABLISHMENT AND ADMINISTRATION OF A

19 PUBLIC HEALTH INSURANCE OPTION.— 

20 ‘‘(1) ESTABLISHMENT.—For years beginning 

21 with 2018, the Secretary of Health and Human 

22 Services (in this subtitle referred to as the ‘Sec23 retary’) shall provide for the offering through Ex24 changes established under this title of a health bene25 fits plan (in this Act referred to as the ‘public health 

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1 insurance option’) that ensures choice, competition, 

2 and stability of affordable, high-quality coverage 

3 throughout the United States in accordance with 

4 this section. In designing the option, the Secretary’s 

5 primary responsibility is to create a low-cost plan 

6 without compromising quality or access to care. 

7 ‘‘(2) OFFERING THROUGH EXCHANGES.— 

8 ‘‘(A) EXCLUSIVE TO EXCHANGES.—The 

9 public health insurance option shall only be 

10 made available through Exchanges established 

11 under this title. 

12 ‘‘(B) ENSURING A LEVEL PLAYING

13 FIELD.—Consistent with this section, the public 

14 health insurance option shall comply with re15 quirements that are applicable under this title 

16 to health benefits plans offered through such 

17 Exchanges, including requirements related to 

18 benefits, benefit levels, provider networks, no19 tices, consumer protections, and cost sharing. 

20 ‘‘(C) PROVISION OF BENEFIT LEVELS.— 

21 The public health insurance option— 

22 ‘‘(i) shall offer bronze, silver, and gold 

23 plans; and 

24 ‘‘(ii) may offer platinum plans. 

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1 ‘‘(3) ADMINISTRATIVE CONTRACTING.—The 

2 Secretary may enter into contracts for the purpose 

3 of performing administrative functions (including 

4 functions described in subsection (a)(4) of section 

5 1874A of the Social Security Act) with respect to 

6 the public health insurance option in the same man7 ner as the Secretary may enter into contracts under 

8 subsection (a)(1) of such section. The Secretary has 

9 the same authority with respect to the public health 

10 insurance option as the Secretary has under sub11 sections (a)(1) and (b) of section 1874A of the So12 cial Security Act with respect to title XVIII of such 

13 Act. Contracts under this subsection shall not in14 volve the transfer of insurance risk to such entity. 

15 ‘‘(4) OMBUDSMAN.—The Secretary shall estab16 lish an office of the ombudsman for the public 

17 health insurance option which shall have duties with 

18 respect to the public health insurance option similar 

19 to the duties of the Medicare Beneficiary Ombuds20 man under section 1808(c)(2) of the Social Security 

21 Act. In addition, such office shall work with States 

22 to ensure that information and notice is provided 

23 that the public health insurance option is one of the 

24 health plans available through an Exchange. 

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1 ‘‘(5) DATA COLLECTION.—The Secretary shall 

2 collect such data as may be required to establish 

3 premiums and payment rates for the public health 

4 insurance option and for other purposes under this 

5 section, including to improve quality and to reduce 

6 racial, ethnic, and other disparities in health and 

7 health care. 

8 ‘‘(6) ACCESS TO FEDERAL COURTS.—The provi9 sions of Medicare (and related provisions of title II 

10 of the Social Security Act) relating to access of 

11 Medicare beneficiaries to Federal courts for the en12 forcement of rights under Medicare, including with 

13 respect to amounts in controversy, shall apply to the 

14 public health insurance option and individuals en15 rolled under such option under this title in the same 

16 manner as such provisions apply to Medicare and 

17 Medicare beneficiaries. 

18 ‘‘(b) PREMIUMS AND FINANCING.— 

19 ‘‘(1) ESTABLISHMENT OF PREMIUMS.— 

20 ‘‘(A) IN GENERAL.—The Secretary shall 

21 establish geographically adjusted premium rates 

22 for the public health insurance option— 

23 ‘‘(i) in a manner that complies with 

24 the premium rules under paragraph (3); 

25 and 

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1 ‘‘(ii) at a level sufficient to fully fi2 nance the costs of— 

3 ‘‘(I) health benefits provided by 

4 the public health insurance option; 

5 and 

6 ‘‘(II) administrative costs related 

7 to operating the public health insur8 ance option. 

9 ‘‘(B) CONTINGENCY MARGIN.—In estab10 lishing premium rates under subparagraph (A), 

11 the Secretary shall include an appropriate 

12 amount for a contingency margin. 

13 ‘‘(2) ACCOUNT.— 

14 ‘‘(A) ESTABLISHMENT.—There is estab15 lished in the Treasury of the United States an 

16 account for the receipts and disbursements at17 tributable to the operation of the public health 

18 insurance option, including the start-up funding 

19 under subparagraph (B). Section 1854(g) of 

20 the Social Security Act shall apply to receipts 

21 described in the previous sentence in the same 

22 manner as such section applies to payments or 

23 premiums described in such section. 

24 ‘‘(B) START-UP FUNDING.— 

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1 ‘‘(i) IN GENERAL.—In order to pro2 vide for the establishment of the public 

3 health insurance option there is hereby ap4 propriated to the Secretary, out of any 

5 funds in the Treasury not otherwise appro6 priated, $2,000,000,000. In order to pro7 vide for initial claims reserves before the 

8 collection of premiums, there is hereby ap9 propriated to the Secretary, out of any 

10 funds in the Treasury not otherwise appro11 priated, such sums as necessary to cover 

12 90 days worth of claims reserves based on 

13 projected enrollment. 

14 ‘‘(ii) AMORTIZATION OF START-UP

15 FUNDING.—The Secretary shall provide for 

16 the repayment of the startup funding pro17 vided under clause (i) to the Treasury in 

18 an amortized manner over the 10-year pe19 riod beginning with 2018. 

20 ‘‘(iii) LIMITATION ON FUNDING.— 

21 Nothing in this subsection shall be con22 strued as authorizing any additional appro23 priations to the account, other than such 

24 amounts as are otherwise provided with remstockstill on DSK30JT082PROD with BILLS

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1 spect to other health benefits plans partici2 pating under the Exchange involved. 

3 ‘‘(3) INSURANCE RATING RULES.—The pre4 mium rate charged for the public health insurance 

5 option may not vary except as provided under sec6 tion 2701 of the Public Health Service Act. 

7 ‘‘(c) PAYMENT RATES FOR ITEMS AND SERVICES.— 

8 ‘‘(1) RATES ESTABLISHED BY SECRETARY.— 

9 ‘‘(A) IN GENERAL.—The Secretary shall 

10 establish payment rates for the public health in11 surance option for services and health care pro12 viders consistent with this subsection and may 

13 change such payment rates in accordance with 

14 subsection (d). 

15 ‘‘(B) INITIAL PAYMENT RULES.— 

16 ‘‘(i) IN GENERAL.—During 2018, 

17 2019, and 2020, the Secretary shall set 

18 the payment rates under this subsection 

19 for services and providers described in sub20 paragraph (A) equal to the payment rates 

21 for equivalent services and providers under 

22 parts A and B of Medicare, subject to 

23 clause (ii), paragraph (4), and subsection 

24 (d). 

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1 ‘‘(ii) EXCEPTIONS.—The Secretary 

2 may determine the extent to which Medi3 care adjustments applicable to base pay4 ment rates under parts A and B of Medi5 care for graduate medical education and 

6 disproportionate share hospitals shall apply 

7 under this section. 

8 ‘‘(C) FOR NEW SERVICES.—The Secretary 

9 shall modify payment rates described in sub10 paragraph (B) in order to accommodate pay11 ments for services, such as well-child visits, that 

12 are not otherwise covered under Medicare. 

13 ‘‘(D) PRESCRIPTION DRUGS.—Payment 

14 rates under this subsection for prescription 

15 drugs that are not paid for under part A or 

16 part B of Medicare shall be at rates negotiated 

17 by the Secretary. 

18 ‘‘(2) SUBSEQUENT PERIODS; PROVIDER NET19 WORK.— 

20 ‘‘(A) SUBSEQUENT PERIODS.—Beginning 

21 with 2021 and for subsequent years, the Sec22 retary shall continue to use an administrative 

23 process to set such rates in order to promote 

24 payment accuracy, to ensure adequate bene25 ficiary access to providers, and to promote afmstockstill on DSK30JT082PROD with BILLS

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1 fordability and the efficient delivery of medical 

2 care consistent with subsection (a)(1). Such 

3 rates shall not be set at levels expected to in4 crease average medical costs per enrollee cov5 ered under the public health insurance option 

6 beyond what would be expected if the process 

7 under paragraph (1)(B) were continued, as cer8 tified by the Office of the Actuary of the Cen9 ters for Medicare & Medicaid Services. 

10 ‘‘(B) ESTABLISHMENT OF A PROVIDER

11 NETWORK.—Health care providers participating 

12 under Medicare are participating providers in 

13 the public health insurance option unless they 

14 opt out in a process established by the Sec15 retary. 

16 ‘‘(3) ADMINISTRATIVE PROCESS FOR SETTING

17 RATES.—Chapter 5 of title 5, United States Code, 

18 shall apply to the process for the initial establish19 ment of payment rates under this subsection but not 

20 to the specific methodology for establishing such 

21 rates or the calculation of such rates. 

22 ‘‘(4) CONSTRUCTION.—Nothing in this section 

23 shall be construed as limiting the Secretary’s author24 ity to correct for payments that are excessive or defi25 cient, taking into account the provisions of submstockstill on DSK30JT082PROD with BILLS

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1 section (a)(1) and any appropriate adjustments 

2 based on the demographic characteristics of enrollees 

3 covered under the public health insurance option, 

4 but in no case shall the correction of payments 

5 under this paragraph result in a level of expendi6 tures per enrollee that exceeds the level of expendi7 tures that would have occurred under paragraph 

8 (1)(B), as certified by the Office of the Actuary of 

9 the Centers for Medicare & Medicaid Services. 

10 ‘‘(5) CONSTRUCTION.—Nothing in this section 

11 shall be construed as affecting the authority of the 

12 Secretary to establish payment rates, including pay13 ments to provide for the more efficient delivery of 

14 services, such as the initiatives provided for under 

15 subsection (d). 

16 ‘‘(6) LIMITATIONS ON REVIEW.—There shall be 

17 no administrative or judicial review of a payment 

18 rate or methodology established under this sub19 section or under subsection (d). 

20 ‘‘(d) MODERNIZED PAYMENT INITIATIVES AND DE21 LIVERY SYSTEM REFORM.— 

22 ‘‘(1) IN GENERAL.—For plan years beginning 

23 with 2018, the Secretary may utilize innovative pay24 ment mechanisms and policies to determine pay25 ments for items and services under the public health 

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1 insurance option. The payment mechanisms and 

2 policies under this subsection may include patient3 centered medical home and other care management 

4 payments, accountable care organizations, value5 based purchasing, bundling of services, differential 

6 payment rates, performance or utilization based pay7 ments, partial capitation, and direct contracting with 

8 providers. Payment rates under such payment mech9 anisms and policies shall not be set at levels ex10 pected to increase average medical costs per enrollee 

11 covered under the public health insurance option be12 yond what would be expected if the process under 

13 subsection (c)(1)(B) were continued, as certified by 

14 the Office of the Actuary of the Centers for Medi15 care & Medicaid Services. 

16 ‘‘(2) REQUIREMENTS FOR INNOVATIVE PAY17 MENTS.—The Secretary shall design and implement 

18 the payment mechanisms and policies under this 

19 subsection in a manner that— 

20 ‘‘(A) seeks to— 

21 ‘‘(i) improve health outcomes; 

22 ‘‘(ii) reduce health disparities (includ23 ing racial, ethnic, and other disparities); 

24 ‘‘(iii) provide efficient and affordable 

25 care; 

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1 ‘‘(iv) address geographic variation in 

2 the provision of health services; or 

3 ‘‘(v) prevent or manage chronic ill4 ness; and 

5 ‘‘(B) promotes care that is integrated, pa6 tient-centered, high-quality, and efficient. 

7 ‘‘(3) ENCOURAGING THE USE OF HIGH VALUE

8 SERVICES.—To the extent allowed by the benefit 

9 standards applied to all health benefits plans partici10 pating under the Exchange involved, the public 

11 health insurance option may modify cost sharing and 

12 payment rates to encourage the use of services that 

13 promote health and value. 

14 ‘‘(4) NON-UNIFORMITY PERMITTED.—Nothing 

15 in this subtitle shall prevent the Secretary from 

16 varying payments based on different payment struc17 ture models (such as accountable care organizations 

18 and medical homes) under the public health insur19 ance option for different geographic areas. 

20 ‘‘(e) PROVIDER PARTICIPATION.— 

21 ‘‘(1) IN GENERAL.—The Secretary shall estab22 lish conditions of participation for health care pro23 viders under the public health insurance option. 

24 ‘‘(2) LICENSURE OR CERTIFICATION.—The Sec25 retary shall not allow a health care provider to parmstockstill on DSK30JT082PROD with BILLS

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1 ticipate in the public health insurance option unless 

2 such provider is appropriately licensed or certified 

3 under State law. 

4 ‘‘(3) PAYMENT TERMS FOR PROVIDERS.— 

5 ‘‘(A) PHYSICIANS.—The Secretary shall 

6 provide for the annual participation of physi7 cians under the public health insurance option, 

8 for which payment may be made for services 

9 furnished during the year, in one of 2 classes: 

10 ‘‘(i) PREFERRED PHYSICIANS.—Those 

11 physicians who agree to accept the pay12 ment rate established under this section 

13 (without regard to cost-sharing) as the 

14 payment in full. 

15 ‘‘(ii) PARTICIPATING, NON-PRE16 FERRED PHYSICIANS.—Those physicians 

17 who agree not to impose charges (in rela18 tion to the payment rate described in sub19 section (c) for such physicians) that exceed 

20 the ratio permitted under section 

21 1848(g)(2)(C) of the Social Security Act. 

22 ‘‘(B) OTHER PROVIDERS.—The Secretary 

23 shall provide for the participation (on an annual 

24 or other basis specified by the Secretary) of 

25 health care providers (other than physicians) 

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1 under the public health insurance option under 

2 which payment shall only be available if the 

3 provider agrees to accept the payment rate es4 tablished under subsection (c) (without regard 

5 to cost-sharing) as the payment in full. 

6 ‘‘(4) EXCLUSION OF CERTAIN PROVIDERS.— 

7 The Secretary shall exclude from participation under 

8 the public health insurance option a health care pro9 vider that is excluded from participation in a Fed10 eral health care program (as defined in section 

11 1128B(f) of the Social Security Act). 

12 ‘‘(f) APPLICATION OF FRAUD AND ABUSE PROVI13 SIONS.—Provisions of law (other than criminal law provi14 sions) identified by the Secretary by regulation, in con15 sultation with the Inspector General of the Department 

16 of Health and Human Services, that impose sanctions 

17 with respect to waste, fraud, and abuse under Medicare, 

18 such as the False Claims Act (31 U.S.C. 3729 et seq.), 

19 shall also apply to the public health insurance option. 

20 ‘‘(g) MEDICARE DEFINED.—For purposes of this sec21 tion, the term ‘Medicare’ means the health insurance pro22 grams under title XVIII of the Social Security Act.’’. 

23 (b) CONFORMING AMENDMENTS.— 

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1 (1) TREATMENT AS QUALIFIED HEALTH

2 PLAN.—Section 1301(a)(2) of the Patient Protection 

3 and Affordable Care Act is amended— 

4 (A) in the heading, by inserting ‘‘, THE

5 PUBLIC HEALTH INSURANCE OPTION,’’ before 

6 ‘‘AND’’; and 

7 (B) by inserting ‘‘the public health insur8 ance option under section 1325,’’ before ‘‘and a 

9 multi-State plan’’. 

10 (2) LEVEL PLAYING FIELD.—Section 1324(a) 

11 of such Act is amended by inserting ‘‘the public 

12 health insurance option under section 1325,’’ before 

13 ‘‘or a multi-State qualified health plan’’. 

14 TITLE II—HEALTH CARE 

15 FINANCIAL ASSISTANCE 

16 SEC. 201. INCREASE IN ELIGIBILITY FOR PREMIUM ASSIST17 ANCE TAX CREDITS. 

18 (a) IN GENERAL.—Subparagraph (A) of section 

19 36B(c)(1) of the Internal Revenue Code of 1986 is amend20 ed by striking ‘‘400 percent’’ and inserting ‘‘600 percent’’. 

21 (b) CONFORMING AMENDMENT.—The table con22 tained in clause (i) of section 36B(b)(3)(A)(i) of the Inter23 nal Revenue Code of 1986 is amended by striking ‘‘400%’’ 

24 and inserting ‘‘600%’’. 

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1 (c) RECONCILIATION OF CREDIT AND ADVANCE

2 CREDIT.—Clause (i) of section 36B(f)(2)(B) of the Inter3 nal Revenue Code of 1986 is amended— 

4 (1) by striking ‘‘In the case of’’ and all that fol5 lows through ‘‘the amount of’’ and inserting ‘‘The 

6 amount of’’; and 

7 (2) by striking ‘‘but less than 400%’’ in the 

8 table. 

9 (d) EFFECTIVE DATE.—The amendments made by 

10 this section shall apply to taxable years beginning after 

11 December 31, 2017. 

12 SEC. 202. ENHANCEMENTS FOR REDUCED COST SHARING. 

13 (a) MODIFICATION OF AMOUNT.— 

14 (1) IN GENERAL.—Section 1402(c)(2) of the 

15 Patient Protection and Affordable Care Act is 

16 amended to read as follows: 

17 ‘‘(2) ADDITIONAL REDUCTION.—The Secretary 

18 shall establish procedures under which the issuer of 

19 a qualified health plan to which this section applies 

20 shall further reduce cost-sharing under the plan in 

21 a manner sufficient to— 

22 ‘‘(A) in the case of an eligible insured 

23 whose household income is not less than 100 

24 percent but not more than 200 percent of the 

25 poverty line for a family of the size involved, inmstockstill on DSK30JT082PROD with BILLS

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1 crease the plan’s share of the total allowed 

2 costs of benefits provided under the plan to 95 

3 percent of such costs; 

4 ‘‘(B) in the case of an eligible insured 

5 whose household income is more than 200 per6 cent but not more than 300 percent of the pov7 erty line for a family of the size involved, in8 crease the plan’s share of the total allowed 

9 costs of benefits provided under the plan to 90 

10 percent of such costs; and 

11 ‘‘(C) in the case of an eligible insured 

12 whose household income is more than 300 per13 cent but not more than 400 percent of the pov14 erty line for a family of the size involved, in15 crease the plan’s share of the total allowed 

16 costs of benefits provided under the plan to 85 

17 percent of such costs.’’. 

18 (2) CONFORMING AMENDMENT.—Clause (i) of 

19 section 1402(c)(1)(B) of such Act is amended to 

20 read as follows: 

21 ‘‘(i) IN GENERAL.—The Secretary 

22 shall ensure the reduction under this para23 graph shall not result in an increase in the 

24 plan’s share of the total allowed costs of 

25 benefits provided under the plan above— 

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1 ‘‘(I) 95 percent in the case of an 

2 eligible insured described in para3 graph (2)(A); 

4 ‘‘(II) 90 percent in the case of an 

5 eligible insured described in para6 graph (2)(B); and 

7 ‘‘(III) 85 percent in the case of 

8 an eligible insured described in para9 graph (2)(C).’’. 

10 (3) EFFECTIVE DATE.—The amendments made 

11 by this subsection shall apply to plan years begin12 ning after December 31, 2017. 

13 (b) FUNDING.—Section 1402 of the Patient Protec14 tion and Affordable Care Act is amended by adding at 

15 the end the following new subsection: 

16 ‘‘(g) FUNDING.—Out of any funds in the Treasury 

17 not otherwise appropriated, there are appropriated to the 

18 Secretary such sums as may be necessary for payments 

19 under this section.’’. 

20 TITLE III—DRUG PRICING 

21 SEC. 301. REQUIRING DRUG MANUFACTURERS TO PROVIDE 

22 DRUG REBATES FOR DRUGS DISPENSED TO 

23 LOW-INCOME INDIVIDUALS. 

24 (a) IN GENERAL.—Section 1860D–2 of the Social 

25 Security Act (42 U.S.C. 1395w–102) is amended— 

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1 (1) in subsection (e)(1), in the matter preceding 

2 subparagraph (A), by inserting ‘‘and subsection (f)’’ 

3 after ‘‘this subsection’’; and 

4 (2) by adding at the end the following new sub5 section: 

6 ‘‘(f) PRESCRIPTION DRUG REBATE AGREEMENT FOR

7 REBATE ELIGIBLE INDIVIDUALS.— 

8 ‘‘(1) REQUIREMENT.— 

9 ‘‘(A) IN GENERAL.—For plan years begin10 ning on or after January 1, 2019, in this part, 

11 the term ‘covered part D drug’ does not include 

12 any drug or biological product that is manufac13 tured by a manufacturer that has not entered 

14 into and have in effect a rebate agreement de15 scribed in paragraph (2). 

16 ‘‘(B) 2018 PLAN YEAR REQUIREMENT.— 

17 Any drug or biological product manufactured by 

18 a manufacturer that declines to enter into a re19 bate agreement described in paragraph (2) for 

20 the period beginning on January 1, 2018, and 

21 ending on December 31, 2018, shall not be in22 cluded as a ‘covered part D drug’ for the subse23 quent plan year. 

24 ‘‘(2) REBATE AGREEMENT.—A rebate agree25 ment under this subsection shall require the manumstockstill on DSK30JT082PROD with BILLS

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1 facturer to provide to the Secretary a rebate for 

2 each rebate period (as defined in paragraph (6)(B)) 

3 ending after December 31, 2017, in the amount 

4 specified in paragraph (3) for any covered part D 

5 drug of the manufacturer dispensed after December 

6 31, 2017, to any rebate eligible individual (as de7 fined in paragraph (6)(A)) for which payment was 

8 made by a PDP sponsor or MA organization under 

9 this part for such period, including payments passed 

10 through the low-income and reinsurance subsidies 

11 under sections 1860D–14 and 1860D–15(b), respec12 tively. Such rebate shall be paid by the manufac13 turer to the Secretary not later than 30 days after 

14 the date of receipt of the information described in 

15 section 1860D–12(b)(7), including as such section is 

16 applied under section 1857(f)(3), or 30 days after 

17 the receipt of information under subparagraph (D) 

18 of paragraph (3), as determined by the Secretary. 

19 Insofar as not inconsistent with this subsection, the 

20 Secretary shall establish terms and conditions of 

21 such agreement relating to compliance, penalties, 

22 and program evaluations, investigations, and audits 

23 that are similar to the terms and conditions for re24 bate agreements under paragraphs (3) and (4) of 

25 section 1927(b). 

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1 ‘‘(3) REBATE FOR REBATE ELIGIBLE MEDICARE

2 DRUG PLAN ENROLLEES.— 

3 ‘‘(A) IN GENERAL.—The amount of the re4 bate specified under this paragraph for a manu5 facturer for a rebate period, with respect to 

6 each dosage form and strength of any covered 

7 part D drug provided by such manufacturer 

8 and dispensed to a rebate eligible individual, 

9 shall be equal to the product of— 

10 ‘‘(i) the total number of units of such 

11 dosage form and strength of the drug so 

12 provided and dispensed for which payment 

13 was made by a PDP sponsor or an MA or14 ganization under this part for the rebate 

15 period, including payments passed through 

16 the low-income and reinsurance subsidies 

17 under sections 1860D–14 and 1860D– 

18 15(b), respectively; and 

19 ‘‘(ii) the amount (if any) by which— 

20 ‘‘(I) the Medicaid rebate amount 

21 (as defined in subparagraph (B)) for 

22 such form, strength, and period, ex23 ceeds 

24 ‘‘(II) the average Medicare drug 

25 program rebate eligible rebate amount 

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1 (as defined in subparagraph (C)) for 

2 such form, strength, and period. 

3 ‘‘(B) MEDICAID REBATE AMOUNT.—For 

4 purposes of this paragraph, the term ‘Medicaid 

5 rebate amount’ means, with respect to each 

6 dosage form and strength of a covered part D 

7 drug provided by the manufacturer for a rebate 

8 period— 

9 ‘‘(i) in the case of a single source 

10 drug or an innovator multiple source drug, 

11 the amount specified in paragraph 

12 (1)(A)(ii)(II) or (2)(C) of section 1927(c) 

13 plus the amount, if any, specified in sub14 paragraph (A)(ii) of paragraph (2) of such 

15 section, for such form, strength, and pe16 riod; or 

17 ‘‘(ii) in the case of any other covered 

18 outpatient drug, the amount specified in 

19 paragraph (3)(A)(i) of such section for 

20 such form, strength, and period. 

21 ‘‘(C) AVERAGE MEDICARE DRUG PROGRAM

22 REBATE ELIGIBLE REBATE AMOUNT.—For pur23 poses of this subsection, the term ‘average 

24 Medicare drug program rebate eligible rebate 

25 amount’ means, with respect to each dosage 

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1 form and strength of a covered part D drug 

2 provided by a manufacturer for a rebate period, 

3 the sum, for all PDP sponsors under part D 

4 and MA organizations administering an MA– 

5 PD plan under part C, of— 

6 ‘‘(i) the product, for each such spon7 sor or organization, of— 

8 ‘‘(I) the sum of all rebates, dis9 counts, or other price concessions (not 

10 taking into account any rebate pro11 vided under paragraph (2) or any dis12 counts under the program under sec13 tion 1860D–14A) for such dosage 

14 form and strength of the drug dis15 pensed, calculated on a per-unit basis, 

16 but only to the extent that any such 

17 rebate, discount, or other price con18 cession applies equally to drugs dis19 pensed to rebate eligible Medicare 

20 drug plan enrollees and drugs dis21 pensed to PDP and MA–PD enrollees 

22 who are not rebate eligible individuals; 

23 and 

24 ‘‘(II) the number of the units of 

25 such dosage and strength of the drug 

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1 dispensed during the rebate period to 

2 rebate eligible individuals enrolled in 

3 the prescription drug plans adminis4 tered by the PDP sponsor or the MA– 

5 PD plans administered by the MA or6 ganization; divided by 

7 ‘‘(ii) the total number of units of such 

8 dosage and strength of the drug dispensed 

9 during the rebate period to rebate eligible 

10 individuals enrolled in all prescription drug 

11 plans administered by PDP sponsors and 

12 all MA–PD plans administered by MA or13 ganizations. 

14 ‘‘(D) USE OF ESTIMATES.—The Secretary 

15 may establish a methodology for estimating the 

16 average Medicare drug program rebate eligible 

17 rebate amounts for each rebate period based on 

18 bid and utilization information under this part 

19 and may use these estimates as the basis for 

20 determining the rebates under this section. If 

21 the Secretary elects to estimate the average 

22 Medicare drug program rebate eligible rebate 

23 amounts, the Secretary shall establish a rec24 onciliation process for adjusting manufacturer 

25 rebate payments not later than 3 months after 

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1 the date that manufacturers receive the infor2 mation collected under section 1860D– 

3 12(b)(7)(B). 

4 ‘‘(4) LENGTH OF AGREEMENT.—The provisions 

5 of paragraph (4) of section 1927(b) (other than 

6 clauses (iv) and (v) of subparagraph (B)) shall apply 

7 to rebate agreements under this subsection in the 

8 same manner as such paragraph applies to a rebate 

9 agreement under such section. 

10 ‘‘(5) OTHER TERMS AND CONDITIONS.—The 

11 Secretary shall establish other terms and conditions 

12 of the rebate agreement under this subsection, in13 cluding terms and conditions related to compliance, 

14 that are consistent with this subsection. 

15 ‘‘(6) DEFINITIONS.—In this subsection and sec16 tion 1860D–12(b)(7): 

17 ‘‘(A) REBATE ELIGIBLE INDIVIDUAL.—The 

18 term ‘rebate eligible individual’ means— 

19 ‘‘(i) a subsidy eligible individual (as 

20 defined in section 1860D–14(a)(3)(A)); 

21 ‘‘(ii) a Medicaid beneficiary treated as 

22 a subsidy eligible individual under clause 

23 (v) of section 1860D–14(a)(3)(B); and 

24 ‘‘(iii) any part D eligible individual 

25 not described in clause (i) or (ii) who is demstockstill on DSK30JT082PROD with BILLS

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1 termined for purposes of the State plan 

2 under title XIX to be eligible for medical 

3 assistance under clause (i), (iii), or (iv) of 

4 section 1902(a)(10)(E). 

5 ‘‘(B) REBATE PERIOD.—The term ‘rebate 

6 period’ has the meaning given such term in sec7 tion 1927(k)(8).’’. 

8 (b) REPORTING REQUIREMENT FOR THE DETER9 MINATION AND PAYMENT OF REBATES BY MANUFACTUR10 ERS RELATED TO REBATE FOR REBATE ELIGIBLE MEDI11 CARE DRUG PLAN ENROLLEES.— 

12 (1) REQUIREMENTS FOR PDP SPONSORS.—Sec13 tion 1860D–12(b) of the Social Security Act (42 

14 U.S.C. 1395w–112(b)) is amended by adding at the 

15 end the following new paragraph: 

16 ‘‘(7) REPORTING REQUIREMENT FOR THE DE17 TERMINATION AND PAYMENT OF REBATES BY MANU18 FACTURERS RELATED TO REBATE FOR REBATE ELI19 GIBLE MEDICARE DRUG PLAN ENROLLEES.— 

20 ‘‘(A) IN GENERAL.—For purposes of the 

21 rebate under section 1860D–2(f) for contract 

22 years beginning on or after January 1, 2019, 

23 each contract entered into with a PDP sponsor 

24 under this part with respect to a prescription 

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1 drug plan shall require that the sponsor comply 

2 with subparagraphs (B) and (C). 

3 ‘‘(B) REPORT FORM AND CONTENTS.—Not 

4 later than a date specified by the Secretary, a 

5 PDP sponsor of a prescription drug plan under 

6 this part shall report to each manufacturer— 

7 ‘‘(i) information (by National Drug 

8 Code number) on the total number of units 

9 of each dosage, form, and strength of each 

10 drug of such manufacturer dispensed to re11 bate eligible Medicare drug plan enrollees 

12 under any prescription drug plan operated 

13 by the PDP sponsor during the rebate pe14 riod; 

15 ‘‘(ii) information on the price dis16 counts, price concessions, and rebates for 

17 such drugs for such form, strength, and 

18 period; 

19 ‘‘(iii) information on the extent to 

20 which such price discounts, price conces21 sions, and rebates apply equally to rebate 

22 eligible Medicare drug plan enrollees and 

23 PDP enrollees who are not rebate eligible 

24 Medicare drug plan enrollees; and 

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1 ‘‘(iv) any additional information that 

2 the Secretary determines is necessary to 

3 enable the Secretary to calculate the aver4 age Medicare drug program rebate eligible 

5 rebate amount (as defined in paragraph 

6 (3)(C) of such section), and to determine 

7 the amount of the rebate required under 

8 this section, for such form, strength, and 

9 period. 

10 Such report shall be in a form consistent with 

11 a standard reporting format established by the 

12 Secretary. 

13 ‘‘(C) SUBMISSION TO SECRETARY.—Each 

14 PDP sponsor shall promptly transmit a copy of 

15 the information reported under subparagraph 

16 (B) to the Secretary for the purpose of audit 

17 oversight and evaluation. 

18 ‘‘(D) CONFIDENTIALITY OF INFORMA19 TION.—The provisions of subparagraph (D) of 

20 section 1927(b)(3), relating to confidentiality of 

21 information, shall apply to information reported 

22 by PDP sponsors under this paragraph in the 

23 same manner that such provisions apply to in24 formation disclosed by manufacturers or whole25 salers under such section, except— 

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1 ‘‘(i) that any reference to ‘this sec2 tion’ in clause (i) of such subparagraph 

3 shall be treated as being a reference to this 

4 section; 

5 ‘‘(ii) the reference to the Director of 

6 the Congressional Budget Office in clause 

7 (iii) of such subparagraph shall be treated 

8 as including a reference to the Medicare 

9 Payment Advisory Commission; and 

10 ‘‘(iii) clause (iv) of such subparagraph 

11 shall not apply. 

12 ‘‘(E) OVERSIGHT.—Information reported 

13 under this paragraph may be used by the In14 spector General of the Department of Health 

15 and Human Services for the statutorily author16 ized purposes of audit, investigation, and eval17 uations. 

18 ‘‘(F) PENALTIES FOR FAILURE TO PRO19 VIDE TIMELY INFORMATION AND PROVISION OF

20 FALSE INFORMATION.—In the case of a PDP 

21 sponsor— 

22 ‘‘(i) that fails to provide information 

23 required under subparagraph (B) on a 

24 timely basis, the sponsor is subject to a 

25 civil money penalty in the amount of 

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1 $10,000 for each day in which such infor2 mation has not been provided; or 

3 ‘‘(ii) that knowingly (as defined in 

4 section 1128A(i)) provides false informa5 tion under such subparagraph, the sponsor 

6 is subject to a civil money penalty in an 

7 amount not to exceed $100,000 for each 

8 item of false information. 

9 Such civil money penalties are in addition to 

10 other penalties as may be prescribed by law. 

11 The provisions of section 1128A (other than 

12 subsections (a) and (b)) shall apply to a civil 

13 money penalty under this subparagraph in the 

14 same manner as such provisions apply to a pen15 alty or proceeding under section 1128A(a).’’. 

16 (2) APPLICATION TO MA ORGANIZATIONS.—Sec17 tion 1857(f)(3) of the Social Security Act (42 

18 U.S.C. 1395w–27(f)(3)) is amended by adding at 

19 the end the following: 

20 ‘‘(D) REPORTING REQUIREMENT RELATED

21 TO REBATE FOR REBATE ELIGIBLE MEDICARE

22 DRUG PLAN ENROLLEES.—Section 1860D– 

23 12(b)(7).’’. 

24 (c) DEPOSIT OF REBATES INTO MEDICARE PRE25 SCRIPTION DRUG ACCOUNT.—Section 1860D–16(c) of the 

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1 Social Security Act (42 U.S.C. 1395w–116(c)) is amended 

2 by adding at the end the following new paragraph: 

3 ‘‘(6) REBATE FOR REBATE ELIGIBLE MEDICARE

4 DRUG PLAN ENROLLEES.—Amounts paid under a re5 bate agreement under section 1860D–2(f) shall be 

6 deposited into the Account.’’. 

7 (d) EXCLUSION FROM DETERMINATION OF BEST

8 PRICE AND AVERAGE MANUFACTURER PRICE UNDER

9 MEDICAID.— 

10 (1) EXCLUSION FROM BEST PRICE DETERMINA11 TION.—Section 1927(c)(1)(C)(ii)(I) of the Social Se12 curity Act (42 U.S.C. 1396r–8(c)(1)(C)(ii)(I)) is 

13 amended by inserting ‘‘and amounts paid under a 

14 rebate agreement under section 1860D–2(f)’’ after 

15 ‘‘this section’’. 

16 (2) EXCLUSION FROM AVERAGE MANUFAC17 TURER PRICE DETERMINATION.—Section 

18 1927(k)(1)(B)(i) of the Social Security Act (42 

19 U.S.C. 1396r–8(k)(1)(B)(i)) is amended— 

20 (A) in subclause (IV), by striking ‘‘and’’ 

21 after the semicolon; 

22 (B) in subclause (V), by striking the period 

23 at the end and inserting ‘‘; and’’; and 

24 (C) by adding at the end the following: 

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1 ‘‘(VI) amounts paid under a re2 bate agreement under section 1860D– 

3 2(f).’’. 

4 SEC. 302. NEGOTIATION OF PRICES FOR MEDICARE PRE5 SCRIPTION DRUGS. 

6 Section 1860D–11 of the Social Security Act (42 

7 U.S.C. 1395w–111) is amended by striking subsection (i) 

8 (relating to noninterference) and inserting the following: 

9 ‘‘(i) NEGOTIATION; NO NATIONAL FORMULARY OR

10 PRICE STRUCTURE.— 

11 ‘‘(1) NEGOTIATION OF PRICES WITH MANUFAC12 TURERS.—In order to ensure that beneficiaries en13 rolled under prescription drug plans and MA–PD 

14 plans pay the lowest possible price, the Secretary 

15 shall have and exercise authority similar to that of 

16 other Federal entities that purchase prescription 

17 drugs in bulk to negotiate contracts with manufac18 turers of covered part D drugs, consistent with the 

19 requirements and in furtherance of the goals of pro20 viding quality care and containing costs under this 

21 part. 

22 ‘‘(2) NO NATIONAL FORMULARY OR PRICE

23 STRUCTURE.—In order to promote competition 

24 under this part and in carrying out this part, the 

25 Secretary may not require a particular formulary or 

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1 institute a price structure for the reimbursement of 

2 covered part D drugs.’’. 

3 SEC. 303. GUARANTEED PRESCRIPTION DRUG BENEFITS. 

4 (a) IN GENERAL.—Section 1860D–3 of the Social 

5 Security Act (42 U.S.C. 1395w–103) is amended to read 

6 as follows: 

7 ‘‘ACCESS TO A CHOICE OF QUALIFIED PRESCRIPTION

8 DRUG COVERAGE

9 ‘‘SEC. 1860D–3. (a) ASSURING ACCESS TO A CHOICE

10 OF COVERAGE.— 

11 ‘‘(1) CHOICE OF AT LEAST THREE PLANS IN

12 EACH AREA.—Beginning on January 1, 2019, the 

13 Secretary shall ensure that each part D eligible indi14 vidual has available, consistent with paragraph (2), 

15 a choice of enrollment in— 

16 ‘‘(A) a nationwide prescription drug plan 

17 offered by the Secretary in accordance with 

18 subsection (b); and 

19 ‘‘(B) at least 2 qualifying plans (as defined 

20 in paragraph (3)) in the area in which the indi21 vidual resides, at least one of which is a pre22 scription drug plan. 

23 ‘‘(2) REQUIREMENT FOR DIFFERENT PLAN

24 SPONSORS.—The requirement in paragraph (1)(B) is 

25 not satisfied with respect to an area if only one enti26 ty offers all the qualifying plans in the area. 

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1 ‘‘(3) QUALIFYING PLAN DEFINED.—For pur2 poses of this section, the term ‘qualifying plan’ 

3 means— 

4 ‘‘(A) a prescription drug plan; 

5 ‘‘(B) an MA–PD plan described in section 

6 1851(a)(2)(A)(i) that provides— 

7 ‘‘(i) basic prescription drug coverage; 

8 or 

9 ‘‘(ii) qualified prescription drug cov10 erage that provides supplemental prescrip11 tion drug coverage so long as there is no 

12 MA monthly supplemental beneficiary pre13 mium applied under the plan, due to the 

14 application of a credit against such pre15 mium of a rebate under section 

16 1854(b)(1)(C); or 

17 ‘‘(C) a nationwide prescription drug plan 

18 offered by the Secretary in accordance with 

19 subsection (b). 

20 ‘‘(b) HHS AS PDP SPONSOR FOR A NATIONWIDE

21 PRESCRIPTION DRUG PLAN.— 

22 ‘‘(1) IN GENERAL.—The Secretary, acting 

23 through the Administrator of the Centers for Medi24 care & Medicaid Services, shall take such steps as 

25 may be necessary to qualify and serve as a PDP 

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•S 1511 IS

1 sponsor and to offer a prescription drug plan that 

2 offers basic prescription drug coverage throughout 

3 the United States. Such a plan shall be in addition 

4 to, and not in lieu of, other prescription drug plans 

5 offered under this part. 

6 ‘‘(2) PREMIUM; SOLVENCY; AUTHORITIES.—In 

7 carrying out paragraph (1), the Secretary— 

8 ‘‘(A) shall establish a premium in the 

9 amount of $37 for months in 2019 and, for 

10 months in subsequent years, in the amount 

11 specified in this paragraph for months in the 

12 previous year increased by the annual percent13 age increase described in section 1860D– 

14 2(b)(6) (relating to growth in medicare pre15 scription drug costs per beneficiary) for the 

16 year involved; 

17 ‘‘(B) is deemed to have met any applicable 

18 solvency and capital adequacy standards; and 

19 ‘‘(C) shall exercise such authorities (includ20 ing the use of regional or other pharmaceutical 

21 benefit managers) as the Secretary determines 

22 necessary to offer the prescription drug plan in 

23 the same or a comparable manner as is the case 

24 for prescription drug plans offered by private 

25 PDP sponsors. 

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1 ‘‘(c) FLEXIBILITY IN RISK ASSUMED.—In order to 

2 ensure access pursuant to subsection (a) in an area the 

3 Secretary may approve limited risk plans under section 

4 1860D–11(f) for the area.’’. 

5 (b) CONFORMING AMENDMENT.—Section 1860D– 

6 11(g) of the Social Security Act (42 U.S.C. 1395w– 

7 111(g)) is amended by adding at the end the following 

8 new paragraph: 

9 ‘‘(8) APPLICATION.—This subsection shall not 

10 apply on or after January 1, 2019.’’. 

11 (c) EFFECTIVE DATE.—The amendments made by 

12 this section shall apply to plan years beginning on or after 

13 January 1, 2019. 

14 SEC. 304. FULL REIMBURSEMENT FOR QUALIFIED RETIREE 

15 PRESCRIPTION DRUG PLANS. 

16 (a) ELIMINATION OF TRUE OUT-OF-POCKET LIMITA17 TION.—Section 1860D–2(b)(4)(C)(iii) of the Social Secu18 rity Act (42 U.S.C. 1395w–102(b)(4)(C)(iii)) is amend19 ed— 

20 (1) in subclause (III), by striking ‘‘or’’ at the 

21 end; 

22 (2) in subclause (IV), by striking the period at 

23 the end and inserting ‘‘; or’’; and 

24 (3) by adding at the end the following new sub25 clause: 

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•S 1511 IS

1 ‘‘(V) under a qualified retiree 

2 prescription drug plan (as defined in 

3 section 1860D–22(a)(2)).’’. 

4 (b) EQUALIZATION OF SUBSIDIES.—Notwithstanding 

5 any other provision of law, the Secretary of Health and 

6 Human Services shall provide for such increase in the spe7 cial subsidy payment amounts under section 1860D– 

8 22(a)(3) of the Social Security Act (42 U.S.C. 1395w– 

9 132(a)(3)) as may be appropriate to provide for payments 

10 in the aggregate equivalent to the payments that would 

11 have been made under section 1860D–15 of such Act (42 

12 U.S.C. 1395w–115) if the individuals were not enrolled 

13 in a qualified retiree prescription drug plan. In making 

14 such computation, the Secretary shall not take into ac15 count the application of the amendments made by section 

16 1202 of the Medicare Prescription Drug, Improvement, 

17 and Modernization Act of 2003 (Public Law 108–173; 117 

18 Stat. 2480). 

19 (c) EFFECTIVE DATE.—This section, and the amend20 ments made by this section, shall take effect on January 

21 1, 2019. 

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1 TITLE IV—MEDICAID 

2 COLLABORATIVE CARE MODELS 

3 SEC. 401. ENHANCED FMAP FOR MEDICAL ASSISTANCE 

4 PROVIDED THROUGH A COLLABORATIVE 

5 CARE MODEL. 

6 Section 1905 of the Social Security Act (42 U.S.C. 

7 1396d) is amended— 

8 (1) in the first sentence of subsection (b)— 

9 (A) by striking ‘‘, and (5)’’ and inserting 

10 ‘‘, (5)’’; and 

11 (B) by inserting ‘‘, and (6) beginning Jan12 uary 1, 2018, the Federal medical assistance 

13 percentage shall be 100 percent with respect to 

14 medical assistance provided by a State for items 

15 and services delivered through a collaborative 

16 care model (as defined in subsection (ee)) or an 

17 evidence-based model (which may be a collabo18 rative care model) that integrates behavioral 

19 health services into primary care treatment’’ be20 fore the period; and 

21 (2) by adding at the end the following new sub22 section: 

23 ‘‘(ee) COLLABORATIVE CARE MODELS.— 

24 ‘‘(1) IN GENERAL.—The term ‘collaborative 

25 care model’ means a model for providing health care 

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1 to individuals which adheres to the core services de2 scribed in paragraph (2) and under which each indi3 vidual receiving care through the model receives care 

4 from a collaborative team of providers described in 

5 paragraph (3). 

6 ‘‘(2) CORE SERVICES.—The services described 

7 in this paragraph are: 

8 ‘‘(A) Comprehensive care management. 

9 ‘‘(B) Care coordination and health pro10 motion. 

11 ‘‘(C) Comprehensive transitional care from 

12 inpatient settings to other settings, including 

13 appropriate follow up. 

14 ‘‘(D) Individual and family support, which 

15 shall include authorized representatives. 

16 ‘‘(E) Referral to community and social 

17 support services, as appropriate. 

18 ‘‘(F) The use of health information tech19 nology to link services, as feasible and appro20 priate. 

21 ‘‘(3) COLLABORATIVE HEALTH TEAM.—A team 

22 described in this paragraph includes the following 

23 providers: 

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50 

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1 ‘‘(A) A primary care provider such as a 

2 primary care physician, an internist, a nurse 

3 practitioner, or a physician’s assistant. 

4 ‘‘(B) Care management staff which shall 

5 include a member who is a registered profes6 sional nurse, a clinical social worker, or a psy7 chologist, and who specializes in primary care 

8 management and is trained to provide evidence 

9 based care coordination, brief behavioral inter10 ventions, and to support treatments (including 

11 medications) initiated by a primary care physi12 cian. 

13 ‘‘(C) A psychiatric consultant who shall 

14 advise the primary care provider as necessary 

15 (either in person or remotely).’’. 

Æ 

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